Is Leaving Residential Treatment the Most Effective Part?

Many of our clients at Alternatives are very experienced in the addiction treatment arena. They’ve been to an average of 3 previous treatment facilities, almost all of which were residential and 12-step based. After each of these stints they experienced a short- to medium-length abstinence period followed by substantial relapse. It was during a session with one such client that the idea for this article came to me:

What if leaving treatment is actually the most effective component of many residential addiction treatment facilities?

Research has shown us time and time again that a 28-day or 30-day stint in treatment is certainly not enough to create lasting change. My own research (1) and NIDA have been using a minimum of 90 days as a generally evidence-supported llength of time to recommend. Still, so much residential treatment focuses on too-short lengths of stay, often resulting in abysmal success rates.

During their stay, clients report being extremely uncomfortable at the beginning, tolerant in the middle and, when successful, excited and happy towards the end. The thinking has been that clients are slowly developing an acceptance that allows them to truly benefit from the amazing treatment they’re receiving – that they are coming to terms with their “powerlessness.”

Could we have it all wrong?

But what if in actuality the only reason for the change in client attitude is a sinking realization that the only way out is to submit? Learned helplessness research (2) supports the idea that if clients believe they are trapped they should become depressed. Displaying positive mood could be a client's only tool of asserting control in residential treatment, allowing them to escape their early depression. Sounds like the opposite of powerlessness.

And what if much of the happiness clients experience at release and the apparent improvement in their behavior immediately following treatment are simply representations of their joy at freedom and earnest desire to never return back to their treatment-industry captors? Having been released from jail before I can tell you that simply leaving is an incredible feeling even though there is absolutely nothing therapeutic about being incarcerated.

I have heard summaries like this from quite a few of our clients. They leave one of the popular name-brand residential facilities and are so happy to get out that they vow never to return. In order to follow through on their promise to themselves and others they do anything they can to appease their families and be cooperative. But within a few weeks, or even days, the lack of any real new tools (assuming they haven’t whole heartedly accepted membership in 12-step culture and lifetime attendance of meetings) leave them unable to deal with life’s stress and they mysteriously find themselves back at square one. Usually with a drink in their hand or a pipe of some sort.

From the outside, this might look like successful treatment that was not followed up on by the client. Indeed, it is often the client who is blamed for the failure. But what if the best part of treatment was simply getting out and the client is simply realizing that they’re lost, confused and left without tools… Who failed them then?

I have always felt that residential treatment in isolation is, in many cases, an absolute waste of time, and can, in fact, be iatrogenic. Addiction is often a result of wider systemic issues, and so to remove the patient from the system will obviously result in behavioural changes, but to simply return them without appropriate coping mechanisms is largely pointless.

Rather residential treatment should form part of a larger case management process. Individuals should be prepared prior to entering, and should be discharged into the continued care of an out-patient program or on going therapy. Personally I feel that it is only a minority of patients that require residential treatment, and it should be one of the final resorts, rather than a knee-jerk initial reaction.

Leaving rehab can also have its' own negative effects. Many people with addiction issues are resolving complex relational issues through their drug use and in initial recovery transfer their primary attachments to the therapist or therapeutic team - the rehab community becomes a family substitute. If this happens, leaving this new "family" is possibly a precipitating factor for relapse, and as such requires some form of therapeutic intervention that goes beyond the residential treatment setting.

Although I am not a fan of life-long 12 step meetings and even more averse to 12-step facilitation based residential programs, the continued involvement in these meetings post-rehab does help resolve the initial relational void that many patients feel.

Shaun, I am always happy to have constructive input and I agree - residential treatment CAN be useful if it is part of a larger treatment plan, although it could also still be traumatic and upsetting and not in the way "therapeutic-communities" want to pretend that it is.
Thanks again for reading!
Dr. J